Provider Demographics
NPI:1275922619
Name:BASTON, DEANNA (LSW)
Entity Type:Individual
Prefix:MS
First Name:DEANNA
Middle Name:
Last Name:BASTON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4895 DRESSLER RD NW
Mailing Address - Street 2:SUITE A
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2571
Mailing Address - Country:US
Mailing Address - Phone:330-493-0083
Mailing Address - Fax:330-493-3689
Practice Address - Street 1:4895 DRESSLER RD NW
Practice Address - Street 2:SUITE A
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2571
Practice Address - Country:US
Practice Address - Phone:330-493-0083
Practice Address - Fax:330-493-3689
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-22
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS11002651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2864191Medicaid